Client Intake Questionnaire

1. Your Personal Information:

Full Name: *

Today's Date

Maiden Name, if applicable:

Want it restored?

Yes

No

Any other name commonly used:

Date of Birth:

Place of Birth:

Full Home Address:

City

State/Province

Zip/Postal

Country

County of Home Address:

Date lived at address since:

Which address do you wish correspondence sent, or if you wish to have it sent to another address, provide that address:

Home Phone Number:

Work Phone Number:

Cell Phone Number:

Fax Number:

Email Address:

Can we send billing/case information to that email?

Yes

No

Please indicate any restrictions/directions in calling you:

Please list any other home address(es) you have had for the past (6) six months:

2. Information About Your Spouse:

Full Name:

Maiden Name, (if any):

Any other names commonly used:

Date of Birth:

Place of Birth:

Home Address

City

State/Province

Zip/Postal

Country

County of Home Address:

Date lived at address since:

Home Phone Number

Work Phone Number

Fax Number

3. Type of Representation Need:

If a modification of an existing settlement agreement or divorce order, who represented you for the divorce?

Who represented your spouse?

4. History of This Marriage

Date of Marriage:

Place of Marriage:

Number of Marriages for You:

Number of Marriages for Your Spouse:

If this is more than the first marriage for you or your spouse, please provide name(s) of prior spouse(s) and how, when, and where prior marriage(s) were terminated.

Are you and your spouse living together now?

If not, when did you separate?

Where were you living at the time of your separation?

When was the last time you and your spouse had sexual relations?

Other than what is listed above, have you and your spouse lived together continuously throughout the marriage?

Yes

No

If not, please explain

If separated, and if all your addresses in the separation are not listed above, please list all other addresses since the separation here:

Please click the "Add" button to add more rows of information.

Address

From

To

Add Remove

5. Information About Your Children

Please click the "Add" button to add information about other children.

Full Name

Date of Birth

Resides With

From which marriage?

Add Remove

Have the children lived with anyone else at any point in time? If so, with whom and at what address?

Do any of the children have special needs requiring extraordinary financial or physical resources that will need to be considered in this case (i.e. learning disability, physical impairment, etc.)? If so, please explain.

Do you anticipate a dispute about custody of the children?

6. Information About Your Employment

Are Your Employed?

Yes

No

If so, where:

Name of Employer:

Employed there since:

Address of Employer:

City

State/Province

Zip/Postal

Country

Job Title:

Gross Yearly Salary:

What is the highest level of educational and vocational training you have (including number of years you attended high school and college, if applicable)?

7. Information About Your Spouse's Employment:

Is your spouse employed?

Yes

No

If so, where:

Name of Employer:

Employed there since:

Address of Employer

City

State/Province

Zip/Postal

Country

Job Title

Gross Yearly Salary:

Please state his/her educational and vocational training (including number of years he/she attended high school and college, if applicable):

8. Prior Proceedings

Has there been any legal or other proceedings between you and your spouse? If so, please explain:

9. Reconciliation

Do you have any interest in reconciliation?

Yes

No

Does your spouse, as far as you know?

Yes

No

Not sure

Have you tried marriage counseling?

Yes

No

If so, when and where?

10. Other:

Has your spouse consulted another attorney regarding this matter?

Yes

No

If so, please indicate his/her name and address if known:

Have you consulted other attorneys about your marital situation?

Yes

No

If yes, whom have you seen and why?

Do you have a will?

Yes

No

If so, who are the beneficiaries?

Do you have an accountant or have you ever used an accountant?

Yes

No

If yes, please state his/her name and address?

Are there any bank accounts, lines of credit, stock and investment accounts or other accounts to which your spouse has access?

Yes

No

If yes, please specify:

Does your spouse have in his or her possession credit cards for which you are responsible? If yes, how many, what type and with which institution?

Have you ever signed anything which may affect the case, including prenuptial or postnuptial agreement(s) or other documents presented by your spouse? If so, please describe what you signed:

Have you or your spouse sold any real estate property in the last five (5) years? If so, please specify:

Who referred you to our office?

May we send a thank you note to him/her?

Yes

No

Client Intake Questionnaire

1. Your Personal Information:

2. Information About Your Spouse:

3. Type of Representation Need:

4. History of This Marriage

If separated, and if all your addresses in the separation are not listed above, please list all other addresses since the separation here:

5. Information About Your Children

6. Information About Your Employment

7. Information About Your Spouse's Employment:

8. Prior Proceedings

9. Reconciliation

10. Other:

Pages

Practice Areas

Contact Info

Search

Client Intake Questionnaire

1. Your Personal Information:

2. Information About Your Spouse:

3. Type of Representation Need:

4. History of This Marriage

If separated, and if all your addresses in the separation are not listed above, please list all other addresses since the separation here:

5. Information About Your Children

6. Information About Your Employment

7. Information About Your Spouse's Employment:

8. Prior Proceedings

9. Reconciliation

10. Other:

Pages

Practice Areas

Contact Info

Search

LEGAL DISCLAIMER